Pharmacology II – Pharmacology II – Respiratory and Respiratory and

OxygenationOxygenation

Kathy Plitnick RN PhD CCRNKathy Plitnick RN PhD CCRN

Georgia Baptist College of Georgia Baptist College of Nursing of Mercer UniversityNursing of Mercer University

AntitussivesAntitussives

Suppress coughSuppress cough NarcoticsNarcotics

CodeineCodeine Non-NarcoticsNon-Narcotics

DextromethorphanDextromethorphan Use: dry, nonproductive coughUse: dry, nonproductive cough

DextromethorphanDextromethorphan

Available over-the-counterAvailable over-the-counter Chemically related to opiatesChemically related to opiates Contraindicated in chronic coughContraindicated in chronic cough Caution in hepatic failureCaution in hepatic failure Rare Side EffectsRare Side Effects Interacts with other CNS depressants, Interacts with other CNS depressants,

Amiodarone, Quinidine, AlcoholAmiodarone, Quinidine, Alcohol

DecongestantsDecongestants

Relieve nasal obstructionRelieve nasal obstruction Adrenergic drugsAdrenergic drugs

Constrict arterioles, reduce blood flowConstrict arterioles, reduce blood flow Mainly alpha receptorsMainly alpha receptors

Oral, topical (sprays & drops)Oral, topical (sprays & drops) Use: relieve rhinitis, preop nasal surgeryUse: relieve rhinitis, preop nasal surgery Contraindicated: HTN, CAD, glaucomaContraindicated: HTN, CAD, glaucoma Sudafed (pseudoephedrine)Sudafed (pseudoephedrine)

Large doses: tachycardia, palpitations, Large doses: tachycardia, palpitations, lightheadednesslightheadedness

AntihistaminesAntihistamines

Prevent effects of histaminePrevent effects of histamine Inhibit smooth muscle constrictionInhibit smooth muscle constriction Decrease capillary permeablityDecrease capillary permeablity Decrease salivation Decrease salivation

Use: allergic rhinitis, anaphylaxis, drug Use: allergic rhinitis, anaphylaxis, drug allergies, transfusions, dermatologic, allergies, transfusions, dermatologic, motion sickness, sleepmotion sickness, sleep

Contraindicated: glaucoma, prostatic Contraindicated: glaucoma, prostatic hypertrophy, pregnancy, bladder hypertrophy, pregnancy, bladder obstructionobstruction

First Generation H1 BlockersFirst Generation H1 Blockers

Bind to central & peripheral H1 receptorsBind to central & peripheral H1 receptors CNS depression/stimulationCNS depression/stimulation Anticholinergic effectsAnticholinergic effects

Interact with alcohol, CNS depressantsInteract with alcohol, CNS depressants Safety precautionsSafety precautions Baseline assessmentBaseline assessment Increase oral fluid intakeIncrease oral fluid intake No drivingNo driving

Diphenhydramine Diphenhydramine (Benadryl)(Benadryl)

High incidence of drowsinessHigh incidence of drowsiness Short term management - insomniaShort term management - insomnia Topical, oral, IM, IVTopical, oral, IM, IV HypotensionHypotension Half-life 1-4 hoursHalf-life 1-4 hours

Second Generation H1 Second Generation H1 BlockersBlockers

Produce less sedationProduce less sedation Less CNS depressionLess CNS depression Fexofenadine (Allegra)Fexofenadine (Allegra)

Rapid absorptionRapid absorption Half-life 14.4 hoursHalf-life 14.4 hours Caution in impaired renal functionCaution in impaired renal function Obtain thorough history of allergic reactionObtain thorough history of allergic reaction Baseline pulmonary assessmentBaseline pulmonary assessment Administration with foodAdministration with food Safety measuresSafety measures

ExpectorantsExpectorants

Liquefy secretionsLiquefy secretions OTC preparationsOTC preparations Guaifenesin (Robitussin)Guaifenesin (Robitussin)

Decreases adhesiveness, surface tensionDecreases adhesiveness, surface tension Well absorbedWell absorbed Symptomatic relief of coughSymptomatic relief of cough Do not use with persistent coughDo not use with persistent cough Rare side effectsRare side effects Assess type, severity of coughAssess type, severity of cough Increase fluid intake, HumidityIncrease fluid intake, Humidity

MucolyticsMucolytics

Inhalation – liquefy mucusInhalation – liquefy mucus Nebulized, Direct instillationNebulized, Direct instillation

Acetylcysteine (Mucomyst)Acetylcysteine (Mucomyst) Reduces viscosity Reduces viscosity Acetaminophen overdoseAcetaminophen overdose Effective in 1 minuteEffective in 1 minute Transient odor, irritated throat, N/V, Transient odor, irritated throat, N/V,

bronchospasmbronchospasm

BronchodilatorsBronchodilators

Adrenergic drugs that stimulate beta2 Adrenergic drugs that stimulate beta2 receptors, stimulate adenyl cyclase, receptors, stimulate adenyl cyclase, increase production of cAMP, produces increase production of cAMP, produces bronchodilationbronchodilation

Xanthines: TheophyllineXanthines: Theophylline Inhibits phosphodiesteraseInhibits phosphodiesterase Inhibits pulmonary edemaInhibits pulmonary edema Helps cilia clear mucusHelps cilia clear mucus Strengthens diaphragmStrengthens diaphragm

TheophyllineTheophylline

Contraindicated: gastritis, PUDContraindicated: gastritis, PUD Uses: asthma, bronchitis, emphysemaUses: asthma, bronchitis, emphysema Aminophylline by continuous infusionAminophylline by continuous infusion Administer with water, after mealsAdminister with water, after meals Monitor plasma levels: 10-20 mcg/mlMonitor plasma levels: 10-20 mcg/ml Avoid smokingAvoid smoking Signs of toxicity: anorexia, N/V, dizziness, Signs of toxicity: anorexia, N/V, dizziness,

shakiness, restlessness, tachycardia, shakiness, restlessness, tachycardia, hypotension, seizureshypotension, seizures

Beta Agonists – AlbuterolBeta Agonists – Albuterol

Available oral, inhalationAvailable oral, inhalation Bronchodilation occurs 5-15 minutesBronchodilation occurs 5-15 minutes Stimulates smooth muscle receptors in Stimulates smooth muscle receptors in

lungs, uterus, skeletal musclelungs, uterus, skeletal muscle Side Effects: throat irritation, Side Effects: throat irritation,

palpitations, Tachycardia, palpitations, Tachycardia, hypertension, finger tremorshypertension, finger tremors

Always administer prior to anti-Always administer prior to anti-inflammatory inhalers, steroidsinflammatory inhalers, steroids

Anticholinergics : Anticholinergics : Ipratropium/AtroventIpratropium/Atrovent

Block action of acetylcholine in Block action of acetylcholine in bronchial smooth musclebronchial smooth muscle

Reduces GMPReduces GMP Halts bronchoconstriction due to PNSHalts bronchoconstriction due to PNS Administration by inhalation, intranasalAdministration by inhalation, intranasal Ineffective in acute bronchospasmIneffective in acute bronchospasm Adverse Effects: cough, nervousness, Adverse Effects: cough, nervousness,

nausea, GI, headachesnausea, GI, headaches

AtroventAtrovent

Do not use as an emergency agentDo not use as an emergency agent MDI’s – allow up to 1 minutes MDI’s – allow up to 1 minutes

between puffsbetween puffs Rinse mouth after administrationRinse mouth after administration

Anti-inflammatory: Anti-inflammatory: Glucocorticoids/BeclomethasonGlucocorticoids/Beclomethason

ee Increase number of beta receptorsIncrease number of beta receptors Increase responsiveness of beta receptorsIncrease responsiveness of beta receptors Produces smooth muscle relaxationProduces smooth muscle relaxation Inhalation: decrease inflammatory cells, Inhalation: decrease inflammatory cells,

and swellingand swelling Chronic asthmaChronic asthma Contraindicated: systemic fungal Contraindicated: systemic fungal

infectionsinfections

BeclomethasoneBeclomethasone

Caution: active infection, DM, PUD, Caution: active infection, DM, PUD, HTN, CHF, RIHTN, CHF, RI

Rinse mouth after administrationRinse mouth after administration Teach proper inhalation techniqueTeach proper inhalation technique Use bronchodilators firstUse bronchodilators first

How Can You Avoid This How Can You Avoid This Medication Error?Medication Error?

Mr. C, 66 years old, has worsening COPD. Mr. C, 66 years old, has worsening COPD. At his last office visit, the MD added At his last office visit, the MD added ipratropium (Atrovent) and ipratropium (Atrovent) and beclomethasone (Vanceril) to his beta-beclomethasone (Vanceril) to his beta-adrenergic (Alupent) inhaler. He visits the adrenergic (Alupent) inhaler. He visits the office complaining of severe dyspnea. You office complaining of severe dyspnea. You quickly grab his Atrovent inhaler to quickly grab his Atrovent inhaler to administer a PRN dose and try to get him administer a PRN dose and try to get him to relax. to relax.

What drug error has occurred, and how What drug error has occurred, and how could this be avoided ??could this be avoided ??

SolutionSolution

Acute dyspnea: only short-acting beta Acute dyspnea: only short-acting beta adrenergic bronchodilators should be used adrenergic bronchodilators should be used (Alupent)(Alupent)

Teach which inhaler to use in an Teach which inhaler to use in an emergencyemergency

When prescribed multiple inhalers, When prescribed multiple inhalers, canister should be a different color or canister should be a different color or marked in some waymarked in some way

Know what the patient is prescribedKnow what the patient is prescribed

Mast Cell Stabilizers: Cromolyn Mast Cell Stabilizers: Cromolyn Sodium (Intal)Sodium (Intal)

No direct anti-inflammatoryNo direct anti-inflammatory Prevents release of mast cells after Prevents release of mast cells after

exposure to allergensexposure to allergens Prophylactic mgmt severe asthma, Prophylactic mgmt severe asthma,

seasonal rhinitisseasonal rhinitis Available oral, inhalation, nasal Available oral, inhalation, nasal

spray, ophthalmicspray, ophthalmic

Cromolyn SodiumCromolyn Sodium

Use proper inhalation techniqueUse proper inhalation technique Wait 10 minutes between dosesWait 10 minutes between doses Rinse mouth after administrationRinse mouth after administration Assess respiratory statusAssess respiratory status

Leukotriene Receptor Leukotriene Receptor Antagonists: Zafirlukast Antagonists: Zafirlukast

(Accolate)(Accolate) Binds to leukotriene receptorsBinds to leukotriene receptors Inhibits bronchoconstrictionInhibits bronchoconstriction Reduces airway edema, smooth Reduces airway edema, smooth

muscle constrictionmuscle constriction Rapidly absorbedRapidly absorbed Half-life 10 hoursHalf-life 10 hours Chronic treatmentChronic treatment

Zafirlukast (Accolate)Zafirlukast (Accolate)

Aspirin increases concentrationAspirin increases concentration Warfarin increases PTWarfarin increases PT Monitor SGPT Monitor SGPT Side effects: headache, diarrhea, gastritisSide effects: headache, diarrhea, gastritis Baseline LFT’sBaseline LFT’s Assess respiratory functionAssess respiratory function Increase fluid intakeIncrease fluid intake Not for acute episodesNot for acute episodes Take on empty stomachTake on empty stomach